Coach Mary: Is this a good fit for me?

Is this a good fit for me?

Coach Mary Lesperance
Date*

MonthDayYear
Today's Date
Name*

First NameLast Name
First Name
Last Name*
Email*
example@example.com
Phone Number*

Area CodePhone Number
City, State*
City, State
How did we connect?*
If you were referred, name of person who referred you.
IDENTIFYING YOUR "WHY"
Describe your health right now. (weight, sleep, stress, energy, etc)*

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Where you would like to be in your health?*

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WHY you are interested in getting healthy? What is your main motivation? (relationships, activities, how you feel, medical, etc.)*

0/330
When do you last remember feeling your best in your health or being at your ideal weight or size?*

0/330
MEDICAL
Are You Pregnant?*

YesNo
Are You Nursing?*

YesNo
Check all that apply:*

Pre-DiabeticDiabetic - Type 1Diabetic - Type 2GoutKidney DiseasePrescribed Coumadin/WarfarinPrescribed LithiumPregnantNursingLow sleep qualityLow energyHigh stress levelsNot currently exercisingMild exercise (no cardio)Moderate exercise (light cardio)Intense exercise (high cardio)High Blood PressureMedication w/Dietary RestrictionsCurrently taking a weight loss pill or supplementCurrently on a Weight Loss ShotConsidering a Weight Loss ShotWas on a weight loss shot but not any moreConsidering bariatric surgeryPrior Bariatric surgery
Any food allergies, sensitivities, dietary restrictions or foods you can't/won't eat?*

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Are you taking any medications for:

DiabetesHigh Blood PressureHigh CholesterolThyroid**Lithium*Coumadin (Warfarin)***
List your medications or medical conditions that have dietary restrictions*

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*Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor
**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the client is on the Program and adjust medication.
***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.

NOTE: It is recommended you consult your healthcare provider prior to starting any weight loss program, and during the course of your weight loss program. Check with your healthcare provider about any dietary restrictions with the medications and supplements you are currently taking. DO NOT USE any Optavia plan if you are pregnant or under the age of 13.
SLEEP
How many hours of sleep do you typically get?
Typical Bedtime
Typical Wake Time
Sleep Quality (scale of 1-10?)
Do you feel rested most days?
HYDRATION
How many ounces of WATER do you drink daily?
Do you drink SODA?
Do you drink TEA?
Do you drink COFFEE?
Do you drink ALCOHOL?
ENERGY & MOTION
How would you rate your energy level? (on a scale of 1-10)
How many times/week do you exercise?
What physical exercise do you participate in? (including physical demands at work)
Are there things you can't do that you would like to be able to?
STRESS
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
EATING HABITS
# of Meals per Day
Time of 1st Meal
Time of Last Meal
Snacking between meals?
What kind of snacks?
How many times a week do you: eat out, delivery, drive thru, takeout, etc
Where do you eat out or order from?
BMI CALCULATION (BODY MASS INDEX)
Current Weight *
Goal Weight *
Height*
Age*
Gender*
WEIGHT LOSS
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?*

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SURROUNDINGS
How healthy would you rate your surroundings? (on a scale of 1-10)
Do you have healthy surroundings & supportive friends and family? Or challenges like junk food in the house, etc?
Is there anyone in your life who would like to get healthy with you?*
$25 gift for each referral. Feel free to share this form with your friends and family.
Would you consider coaching your family & friends?*
Do you prefer online learning or books?
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